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Over the past year, as the assistant director general for non-communicable diseases and mental health at the World Health Organization, Ala Alwan has been coordinating the work of WHO, the UN, NGOs, and the private sector, all of which are assembling at a high-level meeting in New York on Tuesday, formalizing a political declaration that charts a way forward to combat preventable diseases. (Click here to read an investigation into how that declaration came about.) Alwan spoke with Foreign Affairs' Andrew Bast about the urgency of the issue and how NCDs are presenting a new challenge to the developing world.
Non-communicable diseases are a signature agenda item of this year's United Nations General Assembly. Why now?
Because NCDs are now the leading causes of death globally. They are responsible for 63 percent of all deaths around the world. But we now have clear evidence NCDs are not only an enormous health problem, but they are also a development issue with serious socioeconomic consequences. They are a major burden on lower- and middle-income countries. And the problem is increasing significantly.
What will come of the meeting?
On Monday and Tuesday we are expecting 34 heads of state and more than 50 ministers, so one accomplishment will be raising awareness not only among health policymakers, but among members at the highest levels of government that NCDs are linked with social and economic development. The second achievement will be the endorsement of a political declaration, which includes a set of recommendations that place NCDs firmly on the global agenda.
Traditionally NCDs have been a problem for the developed world. Why are they now a development problem?
The fact that a huge number of people are dying too young has a negative impact on productivity, which in turn affects household income. There is also clear evidence both that NCDs contribute to poverty, and that poverty can contribute to NCDs. In India, for instance, the World Bank conducted a study that showed that of families in which one member was affected by cancer, 50 percent of the families experienced a catastrophic expenditure (defined as more than 30 percent of household income). Of those families, 50 percent were driven below the poverty line. It is just one example that NCDs are emerging as cause for poverty.
The declaration says that non-communicable diseases is a "global burden." But aren't problems such as cancer and diabetes the problems of domestic governments?
They are problems of governments, but they are also problems of the international community, particularly in relation to low-income countries. There are two issues. One is development assistance. If you look, less than 3 percent of development assistance is spent on NCDs. So the declaration calls for more priority. Second is the fact that to address NCDs, you have address risk factors, tobacco use, diet, alcohol, physical inactivity, and these are issues influenced by globalization and urbanization.
What role have multinational corporations played in your deliberations?
They were actively involved in a number of meetings and forums. There were many consultations and dialogues organized with the objective of briefing them and trying to identify what their contribution will be in finding solutions. They have not been involved at all in the negotiations that led to the endorsement of the political declarations. But industry needs to be part of the solution. For example, the food and alcohol industry need to reform some of their products, reducing sugar and salt content, reducing trans fat, and they are also responsible for more accountable marketing of food products, especially for children. Then governments have the responsibility to monitor what industry is doing.
Tobacco is entirely different. They are not partners in any kind of negotiations. There is a red line in relation to tobacco industry.
Smoking is on the rise in the developing world. Do governments realize what a massive public health burden is being set in motion?
There is some improvement not only on the part of recognition, but also in the implementation of tobacco control measures. We now have six proven, cost-effective measures, and some of these, such as taxation, actually generate funding for governments. WHO is producing a report every two years monitoring how countries are following guidelines. We have made progress. But yes, the progress is still slow. The vast majority of the world's population is still not protected by tobacco control measures.
Obesity is increasingly a problem in the developing world as well. Haven't we already seen this movie before, particularly in the United States?
It is a major problem because it is increasing in all parts of the world. It is very linked to physical inactivity. You can see if you look at the trends the regions that have the highest rates are the same regions that have the highest rates of inactivity -- the Americas and the Middle East. We still need to demonstrate some successful examples of countries that have managed to stop the increase of obesity rates.
Some have argued that some of these diseases -- obesity, diabetes, and the like -- have now become an inevitable consequence of development.
We have successful examples of reducing cardiovascular disease in industrialized countries. We know that improved healthcare and access can also reduce mortality. This is not an issue that's only caused by behaviors and affluence, but it is caused by unhealthy environments. You have to focus on creating environments that are conducive to healthy choices, and there is no reason those cannot happen with development.
Many developing countries have pressing needs such as better security forces or improved education systems, or even just aid to feed their people. How do you prioritize something like NCDs?
There are two major two priorities any country has to address if it is pursuing sustainable development. One is education. The other is health. There is no way the control of NCDs competes with education. And NCDs is a health issue. What's more, addressing NCDs does not cost a lot of money. In many countries you only need less than $1 per capita per annum to make a real change. So we actually do not see any kind of competition with other kinds of development initiatives.
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